What are the key elements in making the right decision about selecting a psychologist? There are many kinds of professionals who may play different roles in addressing the issues associated with having Asperger Syndrome. How do individuals and families determine what type of professional is needed and how to determine if that person can capably deliver needed treatment?
Diagnosis and Evaluation
Diagnosis of Asperger Syndrome is typically conducted by a psychiatrist, a neurologist, or a psychologist. The result of such diagnosis may range from, “you have Asperger Syndrome,” and little in the way of treatment guidance to a detailed treatment plan and referrals to appropriate professionals. This article will review some of the considerations for obtaining the treatment necessary to improve skills and handle problems associated with this diagnosis.
Interventions Psychologists May Provide
Psychologists have a wide variety of training backgrounds and approaches. The most common orientations are cognitive behavioral, behavioral, psychodynamic, psychoanalytic, and eclectic, that is using a little of each. The age and treatment need should be primary considerations when choosing a therapist to do individual work. Typically, cognitive behavior therapy (CBT) is one of the most effective approaches for children and adults with AS as it addresses the relationship between thoughts and feelings and helps clients change thoughts and behaviors that are not productive. Psychoanalysis and psychodynamic approaches may occasionally be useful for adolescents and adults with AS if they want to explore what led them to develop their current psychological characteristics and how they interact with important others. However, these approaches may have limited usefulness if basic skills still need intervention, as is so frequently the case with children and adults on the spectrum. Behavioral therapists tend to examine the antecedents and consequences of behaviors with the goal of modifying them in positive ways. This kind of approach may be most beneficial as parent or teacher training for those who need assistance helping a child with AS manage.
No matter what the orientation of a particular psychologist, the consumer should inquire about their expertise in dealing with individuals on the autism spectrum and the specifics about how their intended treatment is appropriate and useful. Sometimes adolescents and adults complain that they have spent years with a therapist who did nothing to change their skills or help them solve problems, so not only is it important to choose wisely initially, but it is also critical to reevaluate periodically the effectiveness of ongoing treatment. In recent years, researchers have developed more effective therapeutic tools that psychologists may employ that truly address the unique issues of individuals with AS. But this knowledge is by no means common and professionals who have it must be sought out if one wishes to participate in meaningful treatment.
Psychologists may provide individual psychotherapy, group psychotherapy, individual social skill/cognition treatment, group or dyadic social skills treatment, consultation to schools and programs, parent training, psychoeducation, couples therapy and other unique treatments. An evaluation of an individual’s particular issues should lead to a recommendation of what types of approaches would be most beneficial. As individuals with AS vary so widely it is important that the professional understands that treatments must be as diverse as the individuals who need them. Any of the following may be an individual’s prominent issue, and changes in age or circumstances may moderate some problems but reveal others.
- Individuals with AS may have particular difficulty with the speed of processing visual, social, or auditory information. When everyone around you understands input more efficiently than you, you may quickly become confused or lost. Years of such experience can create a wide gap between the person with AS and the neurotypical world. There are particular strategies to address this issue. If this is a significant problem, it would be wise to ask a provider about what direction treatment for this issue might take.
- Many, but not all, individuals with AS have difficulty with facial recognition and/or understanding nonverbal communication. There are evidence-based interventions that address these specific issues and treatments that can improve function in this area.
- Many individuals on the autism spectrum have a variety of sensory issues. Some diminish with age and others may not. There is a relationship between impaired social skill and degree of sensory over-responsiveness (Hilton et al., 2010.) A psychologist may help an individual, a family, or a teacher understand the effects of sensory sensitivity and how to cope in various environments. An occupational therapist (with expertise in sensory issues) may provide evaluation and treatment of sensory dysfunctions and sensitivities.
- Executive function refers to a wide range of abilities including planning, organization, goal selection, patterns of remembering, flexibility, self-regulation, inhibition, and shifting set. They are called executive functions because they represent the organization and control mechanisms of the brain. Individuals with ADHD, AS, nonverbal learning disability and related conditions may struggle with these issues. Individuals with AS often have particular problems with the self-regulation aspects of behavior associated with executive function deficits (Semrud-Clikeman et al., 2010). Psychologists and neuropsychologists may be able to intervene in productive ways to teach children and adults with these challenges how to cope with these differences or may instruct families or schools who may not understand this type of disability in the context of an otherwise very intelligent person.
- So-called comorbid conditions are those that co-occur with something else. Anxiety disorders and depression are more common for individuals with AS than they are in the neurotypical population (Matilla et al., 2010) and require specific knowledge of Asperger Syndrome to be treated effectively. Gaus (2007) published a book with the specific goal of educating cognitive behavior therapists about AS so that the large numbers of CBT-trained psychologists could be available to those on the spectrum. CBT frequently has been ineffective if the unique aspects of AS are not taken into account. Therapists undertaking such treatment should be queried about their knowledge of AS or their willingness to learn. Gaus’ book has been provided to many therapists by their clients in search of competent CBT treatment.
- Anger management treatment is widely available, but does it take into account the causes for anger a person with AS might have? Generic treatment is unlikely to be useful as individuals with AS may have unique issues that affect anger including poor executive skills, rigid thinking, histories of bullying, poor recognition of specific emotions, or unfair hiring and firing procedures in employment. Carefully assessing the precursors of anger problems requires a thorough understanding of the effects AS may have and the specific circumstances and history of the client.
- Meltdowns (inappropriate behavioral dyscontrol often inconsistent with a person’s age or intellectual maturity) are most often considered to be childhood issues, but adolescents and adults with AS may continue to struggle with behaviors that appear inappropriate, and even frightening to others. Meltdowns may be caused by high levels of anxiety, rigid expectancies, confrontational interactions styles of authority figures and various other difficulties specific to AS. Recognizing the particular cause and having an array of treatment strategies is critical to helping the child or adult with AS remain in inclusive settings and enjoy an acceptable quality of life. Finding a psychologist who understands this issue may make the difference between regular and special education, employment or none, or developing relationships or not.
- Social cognition is a prerequisite for the development of social skills, yet many people try to teach specific social skills in a vacuum. The development of social ability relies on learning to think socially and having an opportunity to practice and generalize. Many different kinds of professionals may offer social skills training. Geller (Autism Spectrum News, 2008) describes ways of judging the usefulness of particular social skills interventions. Professionals in private practice, clinics, or schools should be able to justify their approaches based on research and the individual’s particular skill needs. Psychologists, speech and language pathologists, social workers, mental health counselors and others may provide useful social skills interventions, but should be queried as to their program and experience delivering it, and their specific plans for generalizability in the real world.
Finding a Psychologist
There are many organizations that may be able to help individuals or families get started finding a suitable psychotherapist. Parent groups or adult support groups may well know professionals who have provided high quality care and they may be able to make specific recommendations. University programs that train professionals in autism spectrum conditions may also be a source of this kind of information.
Attending conferences about autism spectrum where clinicians present can also provide a window on a therapist’s level of knowledge, attitudes, and manner. In addition, a conference venue can be a good place to network.
Networking among friends, acquaintances, or professionals you know may also be a good beginning. However, even positive recommendations do not negate the need to ask important questions about experience and understanding of the wide variety of issues that individuals with Asperger Syndrome may present.
The internet has lists of individuals who claim experience with Asperger Syndrome. In addition, there are multiple sites about Asperger Syndrome that can be a starting point for understanding specific issues and finding people with expertise. (www.aspergersyndrome.org, www.faaas.org, www.autism-society.org, www.autismspeaks.org, www.tonyattwood.com.au, www.grasp.org, www.ahany.org, www.aane.org). As with anything on the internet, resources found this way should be carefully vetted.
What Questions Should I Ask?
Nick Dubin (2009) has specifically described approaches for assessing psychotherapists. He notes that it is particularly difficult to find qualified therapists who treat adults. Of particular importance, in his experience, is to avoid professionals whose lack of understanding of AS causes harm. As an adult with AS, Dubin stresses that asking good questions is important to finding someone who can really be of help. As has been enumerated above, there are so many variations of people and problems with AS that one should be seeking a person who “takes a highly individualistic approach with each client and doesn’t use just one particular modality with everyone who has Asperger’s” (Dubin, 2009).
Questions that can help you determine who can best help should include:
- What is your specific training about AS?
- How long have you been working with individuals with AS?
- Do you specialize in children or adults?
- What is your treatment orientation?
- How do you assess what kind of intervention you choose for your clients?
- Are you willing to learn about AS and seek mentorship from a knowledgeable professional in order to provide competent treatment?
- Do you have a working relationship with other clinicians in case other treatment modalities are needed?
In addition to specific questions, it is important to try to gain a feeling for the person’s level of warmth and understanding.
- Explain why you are seeking treatment and listen to how the person responds to your particular issues.
- Assess if the person expresses genuine caring for individuals on the spectrum. A certain level of investment is necessary to work out what can best help individuals with such diversity of being.
- Be prepared to let an introductory session be just that. If a psychologist cannot communicate an initial concept for treatment, he or she may be too inexperienced. It is not uncommon to meet two or three psychologists before making a decision of who is the best person to provide treatment.
In addition, even if you have been in treatment for some time, whomever you are working with should be willing to review progress every so often so that the joint decision to continue, refer elsewhere, or discontinue treatment can be fully considered.
There are a wide variety of professionals who provide psychotherapy including psychologists, psychiatrists, social workers, mental health counselors, or marriage and family therapists. Genuine understanding of Asperger Syndrome may be more important than any particular degree, and finding the right match of knowledge, approach, and authenticity is the key to effective treatment.
Lynda Geller, PhD, is Director of the Institute for Cognitive Diversity at the Bank Street College of Education. She is the founder of the Asperger Center for Education and Training (www.aspergercenter.com), a collaborative effort designed to 1) provide evidence-based, practical, current information about Asperger Syndrome and related conditions and 2) develop and provide innovative services to the community of children and adults with Asperger Syndrome and their families. She is also in private practice in New York City.